Military trauma life support: a comprehensive training program for military physicians

The Israel Defense Forces Medical Corps prepares Israeli physicians for their field duty as providers of prehospital trauma care under combat conditions. Many physicians have no previous experience with emergency medicine. Military trauma education has been improving continuously to meet this challenge. In 1990, the Advanced Trauma Life Support program was launched in Israel. In 1998, a task-oriented approach to military trauma. Military Trauma Life Support, was introduced. This course is integrated in the 3-month training period of medical officers. Its objectives are to provide a comprehensive curriculum in prehospital military trauma, to simulate realistic combat scenarios and injury patterns, and to add practical skills and prehospital experience. The practical section includes definitive airway management in hospital operating rooms, emergency procedures training on cadavers, and prehospital experience on civilian emergency medical services ambulances.     

The soldier-senior officer relationship]

One of the main conditions for the successful adaptation to the military is the relationship between soldier and his commander. The aim of this study was to determine interpersonal relationship between soldier and his commander, evaluated by soldier on the one side and by commander on the other. The sample consisted of 144 adapted (group A) and 400 nonadapted (group NA) soldiers. The applied instruments were two questionnaires: Soldier's evaluation of a commander and Commander's perception of a soldier. Commanders most frequently noticed: emotional reactions of soldiers (anxious and depressive symptoms), then their relation to basic training and performance of soldier's duty and then their adjustment in the group (isolation, problems with sleeping and eating). It was concluded that soldiers with the problems in communication with authority before the military also had the problems with military commanders.     

A method for training combat medics during stability and support operations

Regardless of the conflict situation, highly trained combat medics (medics assigned in maneuver units) are a combat multiplier for military operations. Keeping medics (and physicians) well trained and motivated has many challenges, and we propose a program of instruction in six different nationally recognized courses to address these concerns and achieve the objective of providing medical training in this environment. We tested our program during our recent deployment to Kosovo. A total of 138 certifications were given during a 30-day period to 90% of our population of 120 medics.     

Survey of Israeli Air Force line commander support for fatigue prevention initiatives

BACKGROUND: Sustained and continuous high intensity military operations have increased in scope in recent years. These mandate ever more sophisticated efforts to prevent and ameliorate aviator fatigue. Successful implementation of new fatigue countermeasures requires thorough pretesting among experienced aviator opinion leaders: base and squadron commanders. METHODS: An anonymous and voluntary survey questionnaire containing background material and Likert-scale questions regarding 14 primary through tertiary fatigue prevention initiatives current in the aeromedical literature or unique to the IAF was distributed to all base and flight squadron commanders in the IAF. RESULTS: Of the commanders, 38% returned fully completed questionnaires. The most popular primary prevention initiatives (garnering 87% support) dealt with reservist aviators: 1.) requiring reserve pilots to arrive at the squadron at least 3 h before night flights to facilitate napping time, and 2.) improving scheduling coordination of those reservists employed as civilian aircrew. The chief (88% support) secondary prevention countermeasure endorsed was to utilize stimulant drugs such as caffeine or amphetamines to sustain the alertness of fatigued aviators. Leading the list of tertiary prevention initiatives (75% support) was the suggestion that squadrons debrief the incidence of aviator fatigue, as well as their success in the area of time-management when debriefing high tempo exercises and operational missions. CONCLUSIONS: Commanders differentially supported a wide range of fatigue countermeasures. Use of stimulant drugs achieved the broadest support. Instituting specific measures to facilitate alertness in reservist aviators was also a priority. Surveying the degree of commander support for new fatigue prevention initiatives provides the basis for prioritization of scarce resources, should improve line cooperation, and provides important experience-proven feedback for researchers and policy-makers.     

Role of the battalion surgeon in the Iraq and Afghanistan War

The battalion surgeon is an invaluable asset to a deploying unit. The primary role of a battalion surgeon is to provide basic primary care medicine and combat resuscitation. Other expectations include health care screening, vaccinations, supervision of medics, and being a medical advisor to the unit's commander. As many physicians who fill this role previously worked at medical treatment facilities or medical centers without prior deployment experience, the objective of this article is to highlight some of the challenges a battalion surgeon may encounter before, during, and following deployment.     

Postdeployment mental health screening: an application of the Soldier Adaptation Model

The Global War on Terrorism and its corresponding frequent and long deployments have resulted in an increase in mental health concerns among active duty troops. To mitigate these impacts, the Department of Defense has implemented postdeployment screening initiatives designed to identify symptomatic soldiers and refer them for mental health care. Although the primary purpose of these screenings is to identify and provide assistance to individuals, macrolevel reporting of screening results for groups can assist Commanders, who are charged with ensuring the wellbeing of their soldiers, to make unit-level interventions. This study assesses the utility of a metatheory of occupational stress, the Soldier Adaptation Model, in organizing feedback information provided to Army Commanders on their units' postdeployment screening results. The results of a combat brigade of 2319 soldiers who completed post-deployment screening following return from Iraq were analyzed using Structural Equation Modeling to assess the Soldier Adaptation Model's use for macrolevel reporting. Results indicate the Soldier Adaptation Model did not strengthen the macrolevel reporting; however, alcohol use and reckless driving were found to mediate the relationship between combat exposure and numerous mental health symptoms and disorders (e.g., post-traumatic stress disorder, anger, depression, anxiety, etc.). Research and practice implications are discussed.     

Prevalence of psychotic comorbidity in combat-related post-traumatic stress disorder

OBJECTIVE: We explored the prevalence of comorbidity of psychotic symptoms among Croatian war veterans with combat-related post-traumatic stress disorder (PTSD) and the psychotic features among these patients, as well as the association between psychotic symptoms and personality disorders. METHODS: The study included 680 men who had experienced combat stress and had diagnoses of PTSD confirmed before examination. They were compared with a group of 289 soldiers with combat experience under regular medical examination, who were still in active military service. The groups were matched in duration of combat experience, time elapsed between combat experience and the study, age, marital status, and education. Statistical analyses were performed using the t test and chi2 test. RESULTS: The study showed that 15% of war veterans had current chronic PTSD and 45% had PTSD with one or more comorbid diagnoses. Psychotic disorders with PTSD were confirmed for 17% of those patients and major depressive disorder with psychotic features for 15%. Depression and psychotic symptoms were more often found among patients without personality disorders. Also, we found that 9% of the war veterans who were still in active military service had some psychiatric disorders. CONCLUSIONS: Many patients demonstrated psychotic symptoms different from flashbacks and dissociative symptoms. Those psychotic symptoms are an integral part of PTSD and have a symbolic relation to the trauma.     

Development of a deployment course for graduating military internal medicine residents

Graduates of military internal medicine residency programs are required to have the necessary knowledge and skills to function as internists, military physicians, and military medical leaders. The global war on terrorism has increased the role internists are playing in combat theaters as they fill multiple different military medical positions including battalion, brigade, and division surgeons as well as physicians in echelon I, II, and III medical facilities. Along with general internists, internal medicine subspecialists, pediatricians, and family physicians also fill these roles. Although internal medicine training provides a broad-based knowledge to care for adults, it does not provide significant training in combat casualty care, detainee health care, or environmental health. To overcome many of these perceived shortfalls, we developed the 3-day deployment course for graduating internal medicine residents outlined in this article. Through a combination of didactic and hands-on training, militarily relevant medical knowledge and skills necessary to function at echelon I and II levels of care were provided. Residents uniformly accepted the course with measurable increase in their fund of knowledge at the completion of the course.     

Predictors of burnout among military mental health providers

Mental health treatment of military service members places unique demands on providers as their patients experience combat stress. This study assessed levels and predictors of burnout among mental health providers (N = 97) at military facilities, using a self-administered survey of demographic and work-related measures and the Maslach Burnout Inventory. Burnout levels were comparable to studies of civilian mental health providers but were less severe than those of the Maslach Burnout Inventory normative sample. Working more hours, having more patients with personality disorders, increased patient caseloads, female gender, and being a psychiatrist were predictive of higher burnout scores. Having more confidants at work, a greater percentage of patients with traumatic brain injury, more clinical experience, and being a psychologist predicted lower burnout scores. These findings suggest that burnout levels among military providers are similar to those among civilian providers and may be alleviated by interventions targeting general institutional risk factors.     

Trends of stress fracture prevalence among Israel Defense Forces basic trainees

Stress fractures (SFs) are a common type of overuse injury encountered in training soldiers. High rates of SF may cause a tremendous negative effect on the military unit capability to perform its missions. In this study, we reviewed the medical registry of Israel Defense Forces (IDF) soldiers assigned to combat basic training programs between the years 1998 and 2007. SF rates among IDF combat basic trainees were as high as 20% in several companies during the first years of the study. Amendments in training programs were targeted to fit the different capability and the qualifications required from combat soldiers. As a result, a steady decline of SF rates was observed, with a yearly average of 5% in the later years of the study. Increasing awareness of both medical and commanding personnel to SF and their prevention led to the gradual decline in their frequency observed in IDF basic training programs during recent years.     

Depression and torture.

Torture represents an exceptionally traumatic experience in which horror, helplessness, and hopelessness are extreme. Therefore, it can be expected that depression, along with other trauma-related disorders is present in torture victims at higher rates than in other psychotraumatized individuals. To demonstrate this, we examined two groups of refugees, all suffering the post-traumatic stress disorder. The first group (N = 50) had combat experience but were imprisoned and tortured as well. Members of the second group (N = 29) had combat experience. A third group (N = 30) consisted of local people with no traumatic experience. Using the Hamilton scale, the Beck Depression Inventory and structured dedicated interviews, we tried to determine whether those groups differed in level of depression based on their different levels of traumatic experience. The results of our study indicate that torture victims showed a significantly higher level of depression that is clinically relevant.     

Mass casualty triage knowledge of military medical personnel.

During battlefield and mass casualty incidents, triage has been traditionally performed by many different personnel, including medics, nurses, dentists, and physicians. The objective of this study was to determine which military medical providers are most knowledgeable in mass casualty triage. The design was a prospective, written, timed, case-based examination of triage knowledge. Participants were volunteers from the active duty medical (physician), dental, nursing, and enlisted corps of the three military services. Subjects completed a 16-minute written examination consisting of seven cases in each of three simulated mass casualty scenarios: combat; nuclear, biological, and chemical; and humanitarian. Tests were taken anonymously, although demographic data on medical specialty, training, and experience were collected. Participants were instructed to classify the cases using the NATO categories of immediate, delayed, minimal, or expectant. Scores were tabulated according to two grading scales: an absolute scale of number correct, and a weighted scale amplifying gross misclassifications. Median scores between groups were tested pairwise using the Kruskal-Wallis one-way analysis of variance with p < or = 0.05. Statistically significant differences were noted between the highest and lowest scoring groups in each scenario. Our conclusion is that among the subject groups tested, physicians were best at mass casualty triage. Dentists, nurses, and medics scored progressively less well on our examination.     

Smoking prevalence in military men,and factors affecting this

The aim of the present study was to determine smoking prevalence among noncommissioned officers and privates and the factors affecting it. This study was carried out in a division of 20,000 soldiers. One of every 10 names on the roster was chosen at random. Responses were received from 1,822 subjects (91.1%), all male, in the final month of their 18-month military service with a mean age of 20.3 +/- 2.2 years. Individuals performing their military service were surveyed using a self-administered, anonymous, personal, and voluntary questionnaire. It was determined that 1,160 (63.7%) of the participants were smokers: 180 (9.9%) were occasional smokers, and 980 (53.8) were heavy smokers. For the fathers of the participants, these rates were 15.4% and 40.5%, respectively. The frequency of smoking was found to be higher in subjects who had high incomes, who had high levels of education, whose fathers smoked, and who were raised in environments in which there were many smokers. It was determined that 31.4% of subjects had begun smoking within the previous 2 years during their period of military service.     

Diagnoses, demographics, and utilization of care as encountered by three U.S. Navy general medical officers

U.S. Navy general medical officers (GMOs) are physicians serving as general practitioners. Although exceptions exist, most GMOs are not board-certified in a specialty. They are post-graduate year 1 (PGY-1)-trained, state-licensed physicians analogous to civilian general practitioners. We conducted a retrospective study using data generated from patient visits with active duty males and females from June 1 to 30, 1998, to describe diagnoses, demographics, and utilization of care patterns encountered by three PGY-1-trained GMOs at an ambulatory clinic. A total of 781 patient encounters with 123 diagnoses from a patient population of 3,178 were recorded. This is an average of 260 patient encounters per GMO, at a rate of 2.52 patients seen per patient-care hour. Fifty-seven consultations/referrals were requested (7.3% of encounters, 1.8% of the patient population). Personnel assigned to the clinic accounted for 4.2% of visits (2% of the patient population). Patient satisfaction was rated as "excellent" to "satisfactory," and no significant morbidity was observed at 1.5-year follow-up. With PGY-1 training, GMOs provide primary care to a substantial volume of prescreened patients and treat patients with a majority of diagnoses without referral or unacceptable complications. The role of GMOs, and perhaps other physicians without specialty training (i.e., general practitioners), in selected settings seems valid and may have advantageous medicoeconomic implications for military and civilian managed care systems.     

Women in the Gulf War: combat experience,exposures, and subsequent health care use

The expanding role of women in the military raises questions related to the military experiences of women serving in major conflicts. We assess the military experiences and postwar health care use of women who served during the Gulf War. Data from a population-based survey of military personnel serving between August 1990 and July 1991 assessing military preparedness, combat experience, occupational and other service-related exposures, and health care use were analyzed. Deployed women were more often in the Army, single, without children, college educated, and reported fewer vaccinations. Deployed men and women had similar military experiences; however, men more often participated in combat. Deployed women had more outpatient and inpatient health care use 5 years after deployment and more often received Department of Veterans Affairs compensation than men. If these important differences in exposures and health care use are confirmed in other studies, optimal training and deployment preparedness strategies should be reconsidered.     

Reported stress and its relationship to tobacco use among U.S. military personnel

In addition to common stressors, members of the U.S. Armed Forces experience a high level of stress unique to their status as service members. In an effort to combat stress, many military personnel report high levels of nicotine use. This study investigated the relationship between tobacco use and perceived stress among military members in all four armed services. Results indicate that those who use tobacco products specifically to reduce stress report significantly higher stress levels than those who do not use tobacco. Moreover, current users and those who both smoked and used smokeless tobacco were far more likely to report experiencing "a lot" of stress from a variety of sources than former or never users. Tobacco users also engaged more frequently in negative coping behaviors and relied less on the positive coping strategies used more often by former or never smokers. These findings are consistent with the larger body of literature suggesting that tobacco is not only an ineffective stress-reducing strategy, it also likely perpetuates a stress response in users. It is, therefore, critical that the military improve effective means of coping among nicotine-using troops.     

Occupational stress and psychiatric illness in the military: investigation of the relationship between occupational stress and mental illness among military mental health patients.

OBJECTIVE: This was a pilot study aimed at gathering preliminary data on the relationship between occupational stress and mental illness among military personnel. The primary goal of this study was to determine to what extent military mental health patients report suffering from significant occupational stress. METHODS: Eighty-five active duty military mental health outpatients at the Wilford Hall U.S. Air Force Medical Center mental health clinic answered a 65-item survey that included items on the perception of occupational stress and reported life changes. Participation in this cross-sectional study was anonymous, voluntary, and random. The 85 participants represent 83% of those surveyed and approximately 10% of the clinic's total population of military mental health outpatients. The survey incorporated the 43-item Schedule of Recent Experiences (SRE). By adding the weighted values assigned to the 43 items, each respondent was given an SRE score, which is a measure of overall stress that has been shown to be predictive of future illnesses. RESULTS: A majority (60%) reported suffering from significant work stress. A majority (52%) reported that work stress was causing them significant emotional distress. Almost half (42.5%) reported that work stress was a significant contributor to the onset of their mental illness. The average SRE score for all respondents was 266, reflecting increased risk for future illnesses. Generic work stressors were endorsed more frequently than military-specific stressors. CONCLUSIONS: The results reveal that this population of military mental health clinic outpatients perceived that work stress had a strong negative effect on their emotional health. These results raise the possibility that work stress could be a significant occupational health hazard in the U.S. military, a possibility that warrants further investigation. By gathering additional data on the relationship between work stress and emotional health in the military, interventions can be planned to mitigate the effect of stress caused by the military work environment on the mental health of military personnel.     

Longer-term career outcomes of Uniformed Services University of the Health Sciences Medical School graduates: classes of 1980-1989

BACKGROUND: The Uniformed Services University of the Health Sciences (USUHS) F. Edward Hébert School of Medicine exists to provide physicians who will become leaders in military medicine in both war and peacetime. Studying the career accomplishments of graduates who have reached or are near the end of their military career is one way to assess how well USUHS is meeting this societal charge. METHODS: Self-reported survey of all 2,689 USUHS graduates since its inception in 1976. Data were collected with regard to residency completed, additional degrees obtained, leadership positions and rank obtained, deployment experience, and academic affiliations. RESULTS: Our survey resulted in a 59% response rate (712 of 1,199 respondents) for the matriculating classes of 1980-1989 and a 68% (1,822 of 2,689 respondents) total response rate for all graduates. Career outcome data were analyzed for graduates of the 1980-1989 classes in this article. For this cohort, the board certification rate was 99%; 20% obtained additional degrees; 96% have worked as full-time clinicians; 14% received below-the-zone promotions; 51% had deployed for combat and 42% for humanitarian missions; and 57% continue to hold medical school faculty appointments. DISCUSSION: Many accomplishments, to include high sustained board certification rates from a diverse array of specialties, broad deployment experience, achievement of high leadership responsibilities and senior rank, as well as important contributions to academic medicine were achieved by these graduates. Our results support that USUHS is accomplishing its societal charge.     

Challenges and considerations for managing suicide risk in combat zones

As suicide rates in the military rise, increased attention has been placed on the effective management of high-risk service members. Military mental health professionals deployed to combat zones face a number of challenges and barriers for effective risk management that are unique to the deployed setting. To date, there exists no body of literature identifying areas in which suicide risk management differs between garrison and combat settings to guide mental health professionals in improving clinical decision making with respect to managing suicidal service members in combat zones. On the basis of experience gained during deployments to combat zones, the authors outline several key features of the deployed context that can impact suicide risk and its effective management in combat zones and integrate empirical findings relevant to each issue. Considerations for clinical care and risk management are discussed.